Elisabeth Rosenthal – An American Sickness: Book Review & Audio Summary

Book Info

• Book name: An American Sickness: How Healthcare Became Big Business and How You Can Take Control of the Medical Establishment
• Author: Elisabeth Rosenthal
• Genre: Business & Economics, Social Sciences & Humanities, Health & Wellness
• Pages: 416
• Published Year: 2017
• Publisher: Penguin Press
• Language: English
• Awards: Finalist for the 2017 National Book Award for Nonfiction

Audio Summary

Synopsis

In *An American Sickness*, physician and journalist Elisabeth Rosenthal delivers a scathing examination of how the US healthcare system transformed from a charitable mission into a profit-driven industry. Drawing on her dual expertise as a Harvard-trained doctor and investigative reporter, Rosenthal traces the evolution of American medicine from its humble nonprofit beginnings to today’s corporate behemoth. Through shocking patient stories and meticulous research, she exposes how hospitals operate like Fortune 500 companies, how insurance giants manipulate regulations for maximum profit, and how doctors have become entrepreneurs. More importantly, Rosenthal offers practical strategies for patients to navigate this broken system and advocate for meaningful reform in an industry that desperately needs healing.

Key Takeaways

• The American healthcare system transformed from nonprofit charitable institutions into profit-maximizing corporations starting in the 1970s, fundamentally changing the doctor-patient relationship
• Insurance companies and hospitals have learned to game regulations like the Affordable Care Act, turning requirements meant to protect patients into opportunities for higher profits
• Hospital pricing has become deliberately opaque and arbitrary, with the same procedure costing wildly different amounts depending on business strategy rather than actual costs
• Doctors increasingly function as entrepreneurs with financial incentives tied to billing, creating conflicts of interest that can compromise patient care
• Patients can fight back by questioning bills, negotiating prices, and understanding their rights within this complex system

My Summary

When Healthcare Stopped Being About Health

I’ll be honest—reading Elisabeth Rosenthal’s *An American Sickness* made me angry. Not the kind of fleeting frustration you feel when stuck in traffic, but a deep, simmering anger at a system that has betrayed its most fundamental mission: caring for sick people. As someone who’s navigated medical bills that made absolutely no sense, I found myself nodding along to nearly every page of this book.

Rosenthal, who brings the rare combination of being both a Harvard-trained physician and an investigative journalist for The New York Times, is uniquely positioned to dissect what’s gone wrong with American healthcare. She’s seen the system from both sides of the stethoscope, and her insider perspective gives this book an authority that pure journalism or pure medical expertise alone couldn’t provide.

What struck me most powerfully is how recent this transformation really is. We’re not talking about some ancient, immutable system. The healthcare industry as we know it today—this profit-obsessed machine—essentially took shape within living memory, primarily since the 1970s. That means it can be changed back, or at least reformed. That realization alone makes this book essential reading.

From Charity Wards to Corporate Boardrooms

The book opens with a historical perspective that I found genuinely eye-opening. American healthcare started around 1900 with humble, even noble intentions. The first health insurance policies weren’t designed to make anyone rich—they were meant to compensate workers for lost income during illness. Blue Cross and Blue Shield operated as nonprofits, focused on helping hospitals get paid while keeping costs manageable for patients.

But then came the 1950s, when health insurance purchases jumped by 60% in a single decade. Suddenly, executives realized there was serious money to be made. For-profit companies swooped in, and the industry’s DNA fundamentally changed. The mission shifted from “How do we help people afford care?” to “How much profit can we extract from sick people?”

Rosenthal illustrates this transformation through devastating patient stories. Take Jeffrey Kivey, the New York chemistry teacher with psoriatic arthritis. His regular infusions of Remicade had always cost $19,000 every six weeks—already an astronomical sum. But when his doctor moved to a different hospital, that same infusion suddenly cost $130,000. Not because anything about the treatment changed. Not because the medication became more expensive. Simply because the new hospital’s billing department decided they could charge more.

Here’s the truly perverse part: Jeffrey’s insurance company happily paid that inflated bill without question. Why? Because of a provision in the Affordable Care Act requiring insurers to spend 80-85% of their revenue on patient care. Since insurance companies make obscene amounts of money, they actually need to spend more to comply with regulations. Higher hospital bills help them meet those requirements while still pocketing enormous profits.

This twisted logic exemplifies everything wrong with the system. A regulation designed to protect patients gets weaponized into another profit mechanism. It’s like trying to fix a leaky faucet and accidentally flooding the entire house.

The Business Consultant Invasion

One of the most illuminating sections of the book examines what happened when hospitals started hiring business consultants from firms like Deloitte and Touche in the 1970s. These consultants brought corporate strategies like “strategic pricing” into institutions that had previously operated on a charitable model.

Strategic pricing is a euphemism, of course. What it really means is “charge whatever you think you can get away with.” Hospitals began manipulating bills, raising prices arbitrarily, and optimizing for profit rather than patient outcomes. The transformation from healing institution to profit center was complete.

Rosenthal shares the story of Heather Pierce Campbell, an attorney in Seattle who experienced an ectopic pregnancy in 2014. This is a serious, potentially fatal complication where the embryo grows in the fallopian tube rather than the uterus. Heather needed emergency surgery to remove the tube and embryo—a relatively straightforward procedure that went smoothly.

Then came the bill: over $44,000. For context, that’s more than many Americans earn in an entire year. And the hospital categorized the procedure simply as “miscellaneous,” offering no itemization or justification for the astronomical cost. It was pure profit optimization, dressed up in medical billing codes.

Between 1997 and 2012, hospital service fees increased by 149%. By 2013, an average day in an American hospital cost $4,300—ten times more than a stay in a Spanish hospital. These aren’t small differences we’re talking about. These are orders of magnitude that suggest something fundamentally broken.

As Rosenthal wryly notes, wondering why hospitals charge so much is like wondering why bank robbers rob banks. They do it because that’s where the money is, and because they can get away with it.

When Your Doctor Becomes an Entrepreneur

Perhaps the most troubling transformation Rosenthal documents is how the medical profession itself has changed. In 1990, the American College of Surgeons required members to pledge: “I will set my fees commensurate with the services rendered.” That statement was quietly removed from the pledge in 2004. The symbolism couldn’t be clearer.

Today, roughly 27% of America’s wealthiest one percent are doctors. Now, I’m not suggesting doctors shouldn’t be well compensated—they undergo years of intensive, expensive training and carry enormous responsibility. But we’ve moved far beyond reasonable compensation into territory where medicine has become primarily a wealth-generation strategy.

Doctors now have access to multiple revenue streams that turn them into entrepreneurs. Ambulatory Surgery Centers (ASCs) became popular in the 1980s and 1990s as facilities where doctors could perform outpatient procedures. On the surface, this seems efficient. But many doctors began investing in these centers, creating a financial incentive to recommend procedures that might not be strictly necessary.

When your doctor has a financial stake in the facility where your surgery will be performed, can you trust that their recommendation is based purely on your medical needs? This conflict of interest has become normalized in American medicine in a way that would have been considered deeply unethical just a generation ago.

Hospitals also introduced “productivity bonuses” for doctors—essentially commission-based pay tied to how much they bill. The more procedures a doctor performs, the more tests they order, the higher their compensation. This fundamentally warps the doctor-patient relationship. Instead of “What does this patient need?” the question becomes “What can I bill for?”

Rosenthal also examines how hospitals restructured themselves based on profitability. Departments that didn’t generate enough revenue, like dialysis units, were outsourced or closed. Meanwhile, highly profitable specialties like orthopedics and cardiac care expanded dramatically. Healthcare decisions were being made in boardrooms based on spreadsheets, not in exam rooms based on community health needs.

The Insurance Shell Game

The sections on health insurance particularly resonated with me because, like most Americans, I’ve spent hours on hold with insurance companies trying to understand why a claim was denied or why I owe thousands of dollars for a procedure I thought was covered. Rosenthal pulls back the curtain on how these companies operate.

The history is telling. Blue Cross and Blue Shield once spent 95 cents of every dollar on actual patient care, keeping just 5% for administrative costs and minimal profit. But as the industry became more competitive and profit-focused, that ratio inverted. Insurance companies began keeping as much money as possible, paying out as little as they could get away with.

The Affordable Care Act tried to address this by requiring insurers to spend at least 80-85% of revenue on patient care. But as the Jeffrey Kivey story illustrates, insurance companies found ways to game even this well-intentioned regulation. If you’re required to spend a certain percentage on care, and you’re making billions in revenue, you actually benefit from higher medical costs because your allowed profit (that remaining 15-20%) grows proportionally.

This creates a perverse incentive structure where insurance companies have no motivation to negotiate lower prices. In fact, higher prices can work in their favor. It’s a system designed to extract maximum money from patients and employers while providing minimal actual value.

Why This Matters Right Now

Reading this book in our current moment feels particularly urgent. Healthcare costs continue to rise faster than inflation or wage growth. Medical debt remains the leading cause of personal bankruptcy in America. People ration insulin, skip necessary medications, and avoid doctor visits because they simply cannot afford care.

Meanwhile, we’re the only developed nation without universal healthcare. Americans pay more per capita for healthcare than any other country, yet our outcomes are often worse. We have lower life expectancy, higher infant mortality, and worse management of chronic diseases compared to nations that spend far less.

Rosenthal’s expertise as both a doctor and journalist shines in her analysis of why reform has been so difficult. The healthcare industry employs millions of people and represents nearly 20% of the US economy. Insurance companies, pharmaceutical manufacturers, hospital chains, and medical device makers all have enormous lobbying power. They’ve successfully framed any reform attempt as “government interference” while ignoring that the current system is the result of decades of regulatory capture and market manipulation.

The book also addresses how medical education has changed. Young doctors graduate with crushing debt—often $200,000 or more. This debt burden pushes them toward high-paying specialties and private practices rather than primary care or public health. The system perpetuates itself by ensuring that even well-meaning doctors need to prioritize income over idealism just to pay off their loans.

What You Can Actually Do About It

One of the aspects I most appreciated about *An American Sickness* is that Rosenthal doesn’t just diagnose the problem—she offers practical advice for navigating the system as it currently exists. While individual actions can’t fix systemic problems, they can help protect yourself and your family from the worst financial predations.

She recommends always asking for itemized bills and questioning charges that seem excessive or unclear. Many hospital bills contain errors, duplicate charges, or fees for services never rendered. Simply requesting an itemized breakdown and reviewing it carefully can lead to significant reductions.

Before any non-emergency procedure, ask for a written cost estimate and get it in writing that the facility will not charge more than 125% of the estimate. Negotiate cash prices if you’re uninsured or have a high deductible. Often, the cash price is lower than what insurance would be billed.

For prescriptions, check prices at multiple pharmacies and consider mail-order options or Canadian pharmacies for expensive medications. The same drug can cost vastly different amounts at different locations, and pharmacies rarely volunteer this information.

Rosenthal also advocates for systemic awareness and political engagement. Support candidates who prioritize healthcare reform. Vote for transparency in medical pricing. Demand that your representatives address pharmaceutical costs, surprise medical billing, and insurance company practices.

These individual strategies won’t fix the system, but they can provide some protection while we work toward larger reforms. Think of them as tourniquets—they stop the bleeding temporarily while we figure out how to actually heal the wound.

Where the Book Falls Short

While *An American Sickness* is a powerful critique, it’s not without limitations. Some readers have noted that Rosenthal focuses heavily on problems without offering enough detailed solutions. Her policy recommendations, while sound, can feel somewhat general compared to the specificity of her problem diagnosis.

The book is also quite dense at times. Rosenthal packs in enormous amounts of information—billing codes, insurance regulations, hospital administration details—that can feel overwhelming. I found myself needing to take breaks to process everything, and I imagine readers without a baseline understanding of healthcare policy might struggle with some sections.

Additionally, while Rosenthal’s critique of the profit motive in healthcare is compelling, she doesn’t fully grapple with the complexity of implementing alternatives. Single-payer healthcare, for instance, gets mentioned as a potential solution, but the political and economic challenges of transitioning to such a system receive less attention than they probably deserve.

The book would have also benefited from more international comparison. Rosenthal mentions that American hospital stays cost ten times more than Spanish ones, but deeper analysis of how other countries structure their healthcare systems—and what we might learn from them—would strengthen the argument for reform.

How This Compares to Other Healthcare Books

For those interested in this topic, *An American Sickness* fits into a growing library of healthcare criticism. Steven Brill’s *America’s Bitter Pill* covers similar territory with a focus on the Affordable Care Act’s passage and implementation. T.R. Reid’s *The Healing of America* offers more international perspective, examining healthcare systems around the world.

What distinguishes Rosenthal’s work is her dual perspective as physician and journalist. She understands medical practice from the inside while maintaining the investigative rigor of a reporter. This combination gives the book both emotional resonance and factual authority that purely journalistic or purely medical accounts might lack.

Compared to more academic treatments of healthcare economics, Rosenthal’s book is far more accessible. She uses patient stories to illustrate abstract concepts, making the material engaging even when discussing complex billing practices or insurance regulations. If you’ve been intimidated by healthcare policy books in the past, this is a good entry point.

Questions Worth Considering

After finishing this book, I found myself wrestling with some difficult questions. If healthcare is a human right—as most developed nations have decided—how do we reconcile that with America’s market-based approach? Can a profit motive ever be compatible with optimal patient care, or are these fundamentally opposed goals?

And perhaps most troublingly: How did we allow this to happen? The transformation Rosenthal documents didn’t occur overnight or in secret. It happened gradually, in plain sight, over decades. What does that say about our priorities as a society? About our political system’s ability to protect citizens from predatory industries?

These aren’t questions with easy answers, but they’re questions we need to be asking. Rosenthal’s book provides the information necessary to have informed conversations about healthcare reform, which is the first step toward actually achieving it.

A Diagnosis That Demands Treatment

*An American Sickness* is not an easy read, emotionally or intellectually. It will likely make you angry, frustrated, and perhaps a bit hopeless about the possibility of reform. But it’s also an essential book for anyone who lives in America, pays for healthcare, or cares about social justice.

Rosenthal has written a comprehensive diagnosis of a sick system. Like any good doctor, she doesn’t sugarcoat the prognosis. The American healthcare industry is deeply ill, infected by profit motives that have metastasized throughout every organ of the system. But diagnosis is the first step toward treatment, and this book provides the clarity necessary to understand what we’re dealing with.

What gives me hope is that this system was built by human choices, which means it can be changed by human choices. The nonprofit, patient-focused healthcare system that existed before the 1970s wasn’t perfect, but it was oriented toward healing rather than profit extraction. We can choose to orient our system that way again.

I’d love to hear your experiences with the healthcare system in the comments. Have you faced shocking medical bills? Fought with insurance companies over coverage? Made healthcare decisions based on cost rather than medical need? Sharing our stories is part of building the collective will for change. And if you’ve read *An American Sickness*, what was your biggest takeaway? Did it change how you think about healthcare in America?

This is a conversation we need to keep having, loudly and persistently, until something actually changes. Because right now, the American healthcare system is sick, and we’re all paying the price.